<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <!-- // 姓名输入框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-name" data-rule="required" class="form-control" name="row[name]" type="text">
        </div>
    </div>

    <!-- // 性别选择框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Gender_data')}:</label>
        <div class="col-xs-12 col-sm-8">

            <div class="radio">
                {foreach name="genderDataList" item="vo"}
                <label for="row[gender_data]-{$key}"><input id="row[gender_data]-{$key}" name="row[gender_data]"
                        type="radio" value="{$key}" {in name="key" value="男" }checked{/in} /> {$vo}</label>
                {/foreach}
            </div>

        </div>
    </div>

    <!-- // 身份 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Resident_or_employeed_data')}:</label>
        <div class="col-xs-12 col-sm-8">

            <div class="radio">
                {foreach name="residentOrEmployeedDataList" item="vo"}
                <label for="row[resident_or_employeed_data]-{$key}"><input id="row[resident_or_employeed_data]-{$key}"
                        name="row[resident_or_employeed_data]" type="radio" value="{$key}" {in name="key" value="居民"
                        }checked{/in} /> {$vo}</label>
                {/foreach}
            </div>

        </div>
    </div>

    <!-- // 电话号码输入框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Phone_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-phone_number" data-rule="required" class="form-control" name="row[phone_number]" type="text">
        </div>
    </div>

    <!-- // 身份证号码输入框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Id_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-id_number" data-rule="required" class="form-control" name="row[id_number]" type="text">
        </div>
    </div>

    <!-- // 医保卡号输入框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medical_card_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medical_card_number" data-rule="required" class="form-control" name="row[medical_card_number]"
                type="text">
        </div>
    </div>

    <!-- // 疾病名称ID输入框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('申请病种代码及名称')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-diseaseidname_id" min="0" data-rule="required" data-source="dicts\Diseaseidname\selectpageByID"
                data-field="disease_id_name" class="form-control selectpage" name="row[diseaseidname_id]" type="text"
                value="">
        </div>
    </div>

    <!-- // 指定医院输入框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Designated_hospital')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-designated_hospital" data-rule="required" class="form-control" name="row[designated_hospital]"
                type="text">
        </div>
    </div>

    <!-- // 享受待遇开始日期选择框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Benefit_start_date')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-benefit_start_date" data-rule="required" class="form-control datetimepicker"
                data-date-format="YYYY-MM-DD" data-use-current="true" name="row[benefit_start_date]" type="text"
                value="{:date('Y-m-d')}">
        </div>
    </div>

    <!-- // 专家一输入框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Expert_one')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-expert_one" data-rule="required" data-source="dicts\Expert\selectpageByID" data-field="expert"
                class="form-control selectpage" name="row[expert1_id]" type="text">
        </div>
    </div>

    <!-- // 专家二输入框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Expert_two')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-expert_two" data-rule="required" data-source="dicts\Expert\selectpageByID" data-field="expert"
                class="form-control selectpage" name="row[expert2_id]" type="text">
        </div>
    </div>

    <!-- // 区域 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('区县')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-region_id" min="0" data-rule="required" data-source="dicts\Region\selectpageByID"
                data-field="region" class="form-control selectpage" name="row[region_id]" type="text" value="">
        </div>
    </div>

    <!-- // 诊断选择 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Diagnosis')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-diagnosis" class="form-control" name="row[diagnosis]" type="text">
        </div>
    </div>

    <!-- // 操作时间选择框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Operation_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-operation_time" data-rule="required" class="form-control datetimepicker"
                data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[operation_time]" type="text"
                value="{:date('Y-m-d H:i:s')}">
        </div>
    </div>

    <!-- // 类别数据选择 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Category_data')}:</label>
        <div class="col-xs-12 col-sm-8">

            <div class="radio">
                {foreach name="categoryDataList" item="vo"}
                <label for="row[category_data]-{$key}"><input id="row[category_data]-{$key}" name="row[category_data]"
                        type="radio" value="{$key}" {in name="key" value="肿瘤" }checked{/in} /> {$vo}</label>
                {/foreach}
            </div>

        </div>
    </div>

    <!-- // 操作者输入框 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Operator')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-operator" readonly data-rule="required" class="form-control" name="row[operator]" type="text"
                value={$operator|htmlentities}>
        </div>
    </div>

    <!-- // 备注数据选择 -->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('备注')}:</label>
        <div class="col-xs-12 col-sm-8">

            <div class="radio">
                {foreach name="remarksDataList" item="vo"}
                <label for="row[remarks_data]-{$key}"><input id="row[remarks_data]-{$key}" name="row[remarks_data]"
                        type="radio" value="{$key}" {in name="key" value="备案" }checked{/in} /> {$vo}</label>
                {/foreach}
            </div>

        </div>
    </div>

    <!-- // 提交按钮 -->
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" id="btn-submit-add" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
        </div>
    </div>
</form>